Katie Greenland is a Research Fellow with the Environmental Health Group and has recently collaborated with Adam Biran, Val Curtis, Robert Aunger and Wolf-Peter Schmitt as well as other authors, on a behavioral intervention study in India designed to impove hadwashing. We asked Katie to tell us more about the study….
What are the main findings of the study?
The trial demonstrated that a community-based handwashing campaign based on emotional drivers of behaviour (nurture and disgust) rather than health messaging was able to improve and sustain handwashing with soap at key times – after toilet use and before preparing food, feeding a child or eating.
We found a 15% difference in handwashing rates between intervention and control villages six weeks post-intervention compared with the baseline. When measured six months post-intervention the proportion of key events associated with handwashing increased further in the intervention group while remaining constant in the control group. A shorter intervention run in the control group was able to achieve similar levels of behaviour change.
Were any of the findings unexpected?
We were initially surprised to see that handwashing rates in the intervention villages were higher after six months than they were six weeks post-intervention. However, there was considerable inter-village variability in handwashing rates. Monitoring data suggests that intervention implementation improved during the course of the intervention, which we believe explains the higher rates of handwashing found in the last three villages to receive the intervention. The increase in handwashing rates observed at six months was largely due to behaviour change in the other four villages. It is possible that behaviour change filtered through the population in these initial villages which is why the effect of the intervention of handwashing rates was slower to materialise in these villages.
What should clinicians and patients take away from your report?
The take home message is that a community-based handwashing intervention can improve handwashing behaviour without focussing on health messaging, and that these changes can be sustained over time. Improving handwashing behaviour at household level could significantly improve health outcomes, particularly the risk of diarrhoea among children under-five.
What was one of the most interesting parts of conducting this research for you?
Early one morning during training of our data collectors in a rural village I watched as a young child ate sugar cane, intermittently dragging it along the ground and wrestling it from the mouth of a stray dog. I found myself reflecting on how little we know about the various contribution of different transmission routes to the burden of diarrhoeal disease. In public health I think it is important to focus on achievable goals: I felt comforted when I reminded myself of the health impact of handwashing with soap.
What recommendations do you have for future research as a result of this study?
We recommend other researchers and program implementers adapt and test the Superamma handwashing intervention in other settings. We believe that scaling up the intervention within India could have a positive impact on child health, an effect that should ideally be tested in a larger randomised-controlled trial with health outcomes.
You can also listen to Katie explain about the study in the podcast below.
The full results of the study are available here in the Lancet Global Health Journal.